The power of modeling desired behaviour

Dr. Adrienne Boissy

Q. How do you define the ‘Cleveland Clinic experience’?
Our guiding principle is, ‘Patients First’. Achieving that takes more than world-class clinical care: it requires care that addresses every aspect of a patient’s encounter with the Clinic—from their physical comfort to their educational, emotional and spiritual needs.

We were the first major academic medical centre to make patient experience a strategic goal, the first to appoint a Chief Experience Officer, and one of the first to establish an Office of Patient Experience—which I oversee. Our mission is to ensure consistent, relationship-centred care by partnering with caregivers throughout the Clinic to exceed patient (and family) expectations. Our team of professionals serves as an advisory resource across the Clinic; provides data analytics; identifies and supports sustainable best practices; and collaborates with a variety of departments to ensure the consistent delivery of relationship-centered care.

Q. Ironically, just a few years ago, your patient-experience scores were not very good. Tell us about the quest to change that.
It’s true: we had very low scores a few years ago. But then our CEO, Dr. Toby Cosgrove, had two transformative experiences. Dr. Cosgrove is a cardiac surgeon who had mastered the clinical realm of doctoring: he had multiple patents, was internationally renowned, and was running the Cleveland Clinic.  Shortly after taking on the CEO role, he was at Harvard Business School giving a talk about our approach.  When he finished his talk, a young woman raised her hand and said, ‘That’s all great Dr. Cosgrove; but a while back, I was thinking about where to take my father for heart surgery, and I ultimately decided to take him somewhere else—because I heard that you don’t teach empathy at the Cleveland
Clinic. Dr. Cosgrove, do you teach empathy?’

Toby was floored. He had just presented about our innovative work, but what really mattered to someone in the audience was this concept of empathy. Not only did it matter, but it had influenced where she decided to take her loved one. Shortly thereafter, Toby was in the Middle East, attending the dedication of a hospital, when the hospital’s mission was described ‘serving the body, the spirit, the heart and the soul of our patients’.  When Toby looked out into the audience, he saw people crying, and he was struck by how moved they were by the concept of holistic care. When he returned to the Clinic, he appointed our first-ever Chief Experience Officer and made ‘Patients First’ our strategic priority.

One major step on our journey involved putting 44,000 caregivers through the Cleveland Clinic Experience—a half-day program where people are placed in multidisciplinary groups.  For instance, one group might include a neurosurgeon, a nurse and a housekeeper. They all sit down down with a facilitator and talk about why our work is so important, sharing some of their own stories. They also talk about the Clinic’s values, and how to put Patients First into action.  After each session, everyone made a commitment to the principle that, ‘We are all caregivers’—and   that was a very important cultural shift for us. The next step was to instill some skills around service, with the idea that everybody who works here—at any time—should be able to step in and offer service recovery to every patient they encounter.

Q. Your clinic embraces a group-practice approach, which has been shown to enhance collaboration and innovation.  Describe how it works.
Cleveland Clinic is a non-profit group practice with physician leadership—the second-largest group practice in the world. Our model is fairly unique in that all physicians are on salary. There are no bonuses or financial incentives. All physicians are subject to annual performance reviews and are on one-year contracts.

Our delivery system model is also distinctive. In 2008, we transitioned from the typical profession-oriented organization, designed around physician competencies—such as surgery—to a patient-oriented approach that consists of multiple institutes.  An example is our Heart and Vascular Institute, which is comprised of cardiologists, cardiothoracic surgeons, and vascular surgeons in the same location to handle whatever cardiovascular issue a patient may have. In all, we have 28 such institutes, ranging from Anesthesiology & Pain Management to Wellness, in which caregivers can come together and discuss innovative approaches.

Our institute structure puts patient needs first—ahead of medical practice traditions. It also promotes innovation and the efficient use of resources, representing teamwork at its best to solve complicated problems.

Q. You mentioned that employees at the Clinic—even your CEO—are on one-year renewable contracts. What that does this do for the work culture?
First, it’s intended to be a benefit to our staff and caregivers, who get an opportunity to sit down every year for a performance review. Just before the end of their yearly contract, each staff member sits down with their local leader and a Board of Governors member, and they have a meeting about their performance, how they want to progress, and what some of their challenges are. This really allows us to get a pulse on the culture that people are working in—and any major issues that we should be addressing. It also lets each employee know that we are serious about fostering their development, and that their organization is actively listening to them.  

The second piece is about accountability. Annual reviews are also an opportunity to make sure that we’re messaging our values sufficiently—and holding people accountable for them. As indicated, patient experience is our focus, so that is built into every caregiver’s review process.  Thirdly, perhaps more than anything, is the idea that we are deeply invested in our employees’ success, and if there are things that we need to be doing to make sure they are successful, this provides an opportunity to engage in that, and then execute on it.

Q. One key way to lower costs in the healthcare system is to improve patient outcomes.  What goes into your thinking about that?
As I indicated earlier, we’re coming out of a very doctor-centered era in healthcare, and we have swung into a space where lots of people are talking about a more patient-centered approach.  The Holy Grail is actually what I would call a ‘relationship-centered approach.’ What that means is, as caregivers, we have a chance to bring real value to the table, but patients also bring value to the table.  We have a shared goal, and together, we can design something better than any of us could do alone.  

For example, one of our regional partner hospitals tackled readmission rates and ER visits—both of which are very costly. They reached out to 20 patients who were recently admitted to a local hospital emergency room, through physician or caregiver phone calls to those patients. The calls were intended to check in these patients and make sure a) that they were doing okay and b) to attempt to prevent another ER visit.  This very simple concept had a dramatic impact.  We are finding that, if we can engage people in unique ways, we are able to achieve greater health outcomes; and not just outcomes that we define—but outcomes that our patients help to define.

Q.So, a few years after your CEO was asked about empathy, how do you go about bringing empathy to the patient experience?
Making empathy a reality entails a few different things.  One is encouraging reflective competence.  We’re not an organization that teaches scripted interactions. What I would much rather promote is having people look at the patient sitting in front of them and think about where that patient is, and what words they may need to use on that day to meet that patient where they are.  This work is challenging, because most clinicians are highly intelligent people who have been doing things in a certain way for a long time—and they are probably pretty effective at communicating. That being said, we are lifelong learners, and we should be creating safe, fun environments where we can all learn from each other’s communication techniques.

The second thing we promote is modeling. Organizations are beginning to put patient satisfaction scores in front of their physicians, and it can be tempting to hammer on them about how they’re going to improve those scores.  To me, by doing that you aren’t modeling the very behaviours that you are hoping to instill in your caregivers.  Another way of approaching it would be to say, “Patient satisfaction is one way of capturing the patient experience, and it seems some patients don’t feel that you are communicating very effectively with them; tell me what you think about that’—as opposed to running with judgments that can feel very offensive to an individual clinician, who is likely trying to do their best. In short, it’s about modeling the behaviours we want others to adopt in everything we do as leaders.

A third tool is transparency—being completely up-front with the data we have about patients’ perceptions.  Our clinic has done that internally for about three years.  Every quarter, we provide unedited patient satisfaction data and comments to our physicians. In April of last year, we also took this information public—so now anyone can search online for our physicians and get a sense of what patients are saying about them.

The last piece is resources. You can’t hold people accountable for being empathic and drive transparency around that without having the required resources in place. The fact is, not everybody knows how to be empathic; for some, it comes much more naturally than others. For example, after he went through some of our training, I had a neurosurgeon say to me, “I’ve been waiting my whole life for somebody to tell me what to say in these situations!” It struck me that you can’t just say to somebody, ‘Try to communicate more effectively’ or ‘Do better’; you have to have programs in place that are designed to meet the needs of your people. It took us a long time to develop our program, because we wanted it to be evidence-based—but we also wanted it to include some really creative ways of getting people to think about the challenges of communication and language that effectively conveys that they care.

Your CEO once said, “Data-driven medicine is helpful as an adjunct to the doctor’s experience and intuition, but it’s not a replacement for it.” Describe how you walk that line between Medicine as art and Medicine as science.

The traditional, doctor-centered approach embraces the idea that Medicine is all about science, which it’s clearly not; but it’s not all art, either. It is both, and nowadays, caregivers must do both.  It is no longer enough to master the clinical aspects of what you do—and for many clinicians and caregivers, that is an entirely new concept.

I think the best way to balance the art and science of Medicine is by having a strategy that grabs both peoples’ hearts and minds. As I’ve indicated, that includes modeling empathy, compassion, and relationship-centered care. At the same time, you have to be able to deliver those lofty concepts with some very tangible tools—so that when somebody says, ‘I don’t know what to say in this particular moment’, you can brainstorm with them to come up with language that is authentic for them.  We now have 30 to 40 years of literature on what the best practices are—particularly around communication and empathy. It’s not rocket science, but you do have to create a context where people are receptive to it, and we’ve invested heavily in making sure that the content we deliver speaks to the real challenges our people are facing.

Q. Peter Drucker called healthcare organizations ‘the most complex form of organization that we have ever attempted to manage’. What key lessons do you have for leaders in other industries?
My first lesson would be about modeling.  I have truly come to appreciate the importance of walking the walk and talking the talk. In every single interaction that you have, you should work very hard to model the behaviours that you are trying to drive.  

The second lesson would be around setting expectations.  We talk about ‘Patients First’ all the time—in staff meetings, at executive team meetings, in casual conversations.  We regularly have patients come in and talk to our staff, so their stories are woven deeply into the fabric of how we strategize and operationalize change and innovation here.  But it’s not just about setting a standard: it’s about holding people accountable to that standard—not just in a punitive way, but in a very human way.  

The other day, I was off duty, sitting in a close relative’s room, in plain clothes, when a caregiver came in. She didn’t introduce herself, and she started to ask me a number of questions. I immediately said, “I would be happy to answer those questions, as soon as I know who you are and what role you are playing in my relative’s care.”  At that moment, it struck me that, all-too often, we let these moments go. Without any real context, we just answer the questions. I think we have to start reflecting back the undesirable behaviour, right then and there—by saying, ‘Lets rewind.  I appreciate that you may be very busy and I’d like you to take a minute to introduce yourself.’

I have come around to the idea that organizational culture is made up of a thousand different choices that are made each and every day. As a leader, if you see behaviour that doesn’t fit with the culture you aspire to, you have to call it out; and of course, you should also call it out when it does meet expectations.  The question is, What choices are we all making, every moment, to create the culture that we aspire to?

Dr. Adrienne Boissy is the Chief Experience Officer at the Cleveland Clinic, based in Cleveland, Ohio.
Reprinted with permission from the Winter 2016 edition of Rotman Management, published by the University of Toronto’s Rotman School of Management. www.rotmanmagazine.ca

[This article has been reprinted, with permission, from Rotman Management, the magazine of the University of Toronto's Rotman School of Management]